Endoscopic ultrasound elastography

Julio Iglesias-Garcia, Björn Lindkvist, Jose Lariño-Noia, J Enrique Domínguez-Muñoz, Julio Iglesias-Garcia, Björn Lindkvist, Jose Lariño-Noia, J Enrique Domínguez-Muñoz

Abstract

Endoscopic ultrasound (EUS) is a reference technique for diagnosing and staging several different diseases. EUS-guided biopsies and fine needle aspirations are used to improve diagnostic performance of cases where a definitive diagnosis cannot be obtained through conventional EUS. However, EUS-guided tissue sampling requires experience and is associated with a low but not negligible risk of complications. EUS elastography is a non-invasive method that can be used in combination with conventional EUS and has the potential for improving the diagnostic accuracy and reducing the need for EUS-guided tissue sampling in several situations. Elastography measures tissue stiffness by evaluating changes in the EUS image before and after the application of slight pressure to the target tissue by the ultrasonography probe. Pathologic processes such as cancerization and fibrosis alter tissue elasticity and therefore induce changes in elastographic appearance. Qualitative elastography depicts tissue stiffness using different colors, whereas quantitative elastography renders numerical results expressed as a strain ratio or hue histogram mean. EUS elastography has been proven to differentiate between benign and malignant solid pancreatic masses, as well as between benign and malignant lymph nodes with a high accuracy. Studies have also demonstrated that the early changes of chronic pancreatitis can be distinguished from normal pancreatic tissues under EUS elastography. In this article, we review the technical aspects and current clinical applications of qualitative and quantitative EUS elastography and emphasize the potential additional indications that need to be evaluated in future clinical studies.

Keywords: elastography; endoscopic ultrasound; lymph nodes; pancreatic tumors.

Figures

Figure 1
Figure 1
Qualitative EUS elastography of a pancreatic cancer showing a specific color distribution
Figure 2
Figure 2
Quantitative EUS elastography based on hue histogram analysis of a metastatic intraabdominal lymph node (gastric adenocarcinoma). The histogram analysis was performed on a selected area within the region of interest. The mean value of this evaluation is shown at the bottom of the image (14.5).
Figure 3
Figure 3
Quantitative EUS elastography based on strain ratio analysis of a solid pancreatic mass (pancreatic adenocarcinoma). We selected area A to represent pancreatic parenchyma, and area B to correspond to a soft area from the gut wall. The B/A ratio is displayed at the bottom of the image (55.66).
Figure 4
Figure 4
Quantitative EUS elastography showing different hue histogram (A) and strain ratio (B) values, as well as the basal appearance of pancreatic solid lesions. I) Pancreatic adenocarcinoma; II) Inflammatory mass in chronic pancreatitis; III) Neuroendocrine pancreatic tumor.
Figure 5
Figure 5
Quantitative EUS elastographic evaluation of a patient with EUS findings suggestive of chronic pancreatitis
Figure 6
Figure 6
Qualitative EUS elastography of a lymph node patient with EUS findings suggestive of chronic pancreatitis showing a predominantly blue pattern in a patient with non-small cell lung cancer with malignant lymph node metastasis

References

    1. Dye CE, Waxman I. Endoscopic ultrasound. Gastroenterol Clin North Am. 2002;31:863–79.
    1. Tamerisa R, Irisawa A, Bhutani MS. Endoscopic ultrasound in the diagnosis, staging, and management of gastrointestinal and adjacent malignancies. Med Clin North Am. 2005;89:139–58.
    1. Byrne MF, Jowell PS. Gastrointestinal imaging: endoscopic ultrasound. Gastroenterology. 2002;122:1631–48.
    1. Iglesias García J, Lariño Noia J, Domínguez Muñoz JE. Endoscopic ultrasound in the diagnosis and staging of pancreatic cancer. Rev Esp Enferm Dig. 2009;101:631–8.
    1. Giovannini M. The place of endoscopic ultrasound in bilio-pancreatic pathology. Gastroenterol Clin Biol. 2010;34:436–45.
    1. Gill KR, Wallace MB. Endoscopic ultrasound and staging of non-small cell lung cancer. Minerva Med. 2007;98:323–30.
    1. De Luca L, Di Bella S, D’Amore E. Mediastinal and gastric EUS: indications and technique examination. Minerva Med. 2007;98:423–9.
    1. Erickson RA. EUS-guided FNA. Gastrointest Endosc. 2004;60:267–79.
    1. Dumonceau JM, Polkowski M, Larghi A, et al. Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2011;43:897–912.
    1. Turner BG, Cizinger S, Agarwal D, et al. Diagnosis of pancreatic neoplasia with EUS-FNA: a report of accuracy. Gastrointest Endosc. 2010;71:91–8.
    1. Iglesias-García J, Dominguez-Muñoz JE, Lozano-Leon A, et al. Impact of endoscopic-ultrasound fine needle biopsy for diagnosis of pancreatic masses. World J Gastroenterol. 2007;13:289–93.
    1. Chang KJ, Nguyen P, Erickson RA, et al. The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma. Gastrointest Endosc. 1997;45:387–93.
    1. Vilmann P, Annema J, Clementsen P. Endosonography in bronchopulmonary disease. Best Pract Res Clin Gastroenterol. 2009;23:711–28.
    1. Nguyen TQ, Kalade A, Prasad S, et al. Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) of mediastinal lesions. ANZ J Surg. 2011;81:75–8.
    1. Erickson RA, Sayage-Rabie L, Beisner RS. Factors’ predicting the number of EUS-guided fine-needle passes for diagnosis of pancreatic malignancies. Gastrointest Endosc. 2000;51:184–90.
    1. Binmoeller KF, Rathod VD. Difficult pancreatic mass FNA: tips for success. Gastrointest Endosc. 2002;56:S86–93.
    1. Varadarajulu S, Tamhane A, Eloubeidi MA. Yield of EUS-guided FNA of pancreatic masses in the presence or the absence of chronic pancreatitis. Gastrointest Endosc. 2005;62:728–36.
    1. Bhutani MS, Hawes RH, Hoffman BJ. A comparison of the accuracy of echo features during endoscopic ultrasound (EUS) and EUSguided fine needle aspiration for diagnosis of malignant lymph node invasion. Gastrointest Endosc. 1997;45:474–9.
    1. Micames C, Jowell PS, White R, et al. Lower frequency of peritoneal carcinomatosis in patients with pancreatic cancer diagnosed by EUS-guided FNA vs. percuteneous FNA. Gastrointest Endosc. 2003;58:690–5.
    1. Eloubeidi MA, Tamhane A, Varadajulu S. Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation. Gastrointest Endosc. 2006;63:622–9.
    1. Kitano M, Kudo M, Sakamoto H, et al. Endoscopic ultrasonography and contrast-enhanced endoscopic ultrasonography. Pancreatology. 2011;11:28–33.
    1. Saftiou A. State-of-the-art imaging techniques in endoscopic ultrasound. World J Gastroenterol. 2011;17:691–6.
    1. Itoh A, Ueno E, Tohno E, et al. Breast disease: clinical application of US elastography for diagnosis. Radiology. 2006;239:341–50.
    1. Cochlin DL, Ganatra RH, Griffiths DFR. Elastography in the detection of prostatic cancer. Clin Radiol. 2002;57:1014–20.
    1. Krouskop TA, Wheeler TM, Kallel F, et al. Elastic moduli of breast and prostate tissues under compression. Ultrasonic Imaging. 1998;20:260–74.
    1. Giovannini M. Contrast-enhanced endoscopic ultrasound and elastosonoendoscopy. Best Prac Res Clin Gastroenterol. 2009;23:767–79.
    1. Chaudhari MH, Forsberg F, Voodarla A, et al. Breast tumor vascularity identified by contrast enhanced ultrasound and pathology: initial results. Ultrasonics. 2000;38:105–9.
    1. Fornage BD. Recent advances in breast sonography. JBR-BTR. 2000;83:75–80.
    1. Garra BS, Cespedes EI, Ophir J, et al. Elastography of breast lesions: initial clinical results. Radiology. 1997;202:79–86.
    1. Gao L, Parker KJ, Lerner RM, et al. Imaging of the elastic properties of tissue – a review. Ultrasound Med Biol. 1996;22:959–97.
    1. Ophir J, Cespedes EI, Garra BS, et al. Elastography: ultrasound imaging of tissue strain and elastic modulus in vivo. Eur J Ultrasound. 1996;3:49–70.
    1. Giovannini M. Endoscopic Ultrasound Elastography. Pancreatology. 2011;11:34–9.
    1. Frey H. Real-time elastography. A new ultrasound procedure for the reconstruction of tissue elasticity. Radiologie. 2003;43:850–5.
    1. Iglesias-Garcia J, Lariño-Noia J, Abdulkader I, et al. Endoscopic Ultrasound Elastography for the characterization of solid pancreatic masses. Gastrointest Endosc. 2009;70:1101–8.
    1. Săftoiu A, Vilmann P, Gorunescu F, et al. Neural network analysis of dynamic sequences of EUS-elastography used for the differential diagnosis of chronic pancreatitis and pancreatic cancer. Gastrointest Endosc. 2008;68:1086–94.
    1. Ferreira T, Rasband W. The ImageJ User Guide – Version 1.44. Available from .
    1. Hirooka Y, Itoh A, Kawashima H, et al. Diagnosis of pancreatic disorders using contrast-enhanced endoscopic ultrasonography and endoscopic elastography. Clin Gastroenterol Hepatol. 2009;7:S63–7.
    1. Iglesias-Garcia J, Lariño-Noia J, Abdulkader I, et al. Quantitative endoscopic ultrasound elastography: an accurate method for the differentiation of solid pancreatic masses. Gastroenterology. 2010;139:1172–80.
    1. Seicean A. Endoscopic Ultrasound in chronic pancreatitis: where are we now? World J Gastroenterol. 2010;16:4253–63.
    1. Brugge WR. Evaluation of pancreatic cystic lesions with EUS. Gastrointest Endosc. 2004;59:698–707.
    1. Galasso D, Carnuccio A, Larghi A. Pancreatic cancer: diagnosis and endoscopic staging. Eur Rev Med Pharmacol Sci. 2010;14:375–85.
    1. Giovannini M, Hookey LC, Bories E, et al. Endoscopic Ultrasound elastography: the first step towards virtual biopsy? preliminary results in 49 patients. Endoscopy. 2006;38:344–8.
    1. Giovannini M, Botelberge T, Bories E, et al. Endoscopic ultrasound elastography for evaluation of lymph nodes and pancreatic masses: a multicenter study. World J Gastroenterol. 2009;15:1587–93.
    1. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;147:1123–6.
    1. Janssen J, Schlörer E, Greiner L. EUS-elastography of the pancreas: feasibility and pattern description of the normal pancreas, chronic pancreatitis, and focal pancreatic lesions. Gastrointest Endosc. 2007;65:971–8.
    1. Hirche TO, Ignee A, Barreiros AP, et al. Indications and limitations of endoscopic ultrasound elastography for evaluation of focal pancreatic lesions. Endoscopy. 2008;40:910–7.
    1. Itokawa F, Itoi T, Sofuni A, et al. EUS elastography combined with the strain ratio of tissue elasticity for diagnosis of solid pancreatic masses. J Gastroenterol. 2011;46:843–53.
    1. Dietrich CF, Hirche TO, Ott M, et al. Real-time tissue elastography in the diagnosis of autoimmune pancreatitis. Endoscopy. 2009;41:718–20.
    1. Saftoiu A, Vilmann P, Gorunescu F, et al. Accuracy of endoscopic ultrasound elastography used for differential diagnosis of focal pancreatic masses: a multicenter study. Endoscopy. 2011;43:596–603.
    1. Schrader H, Wiese M, Ellrichmann M, et al. Diagnostic value of quantitative eus elastography for malignant pancreatic tumors: relationship with pancreatic fibrosis. Ultraschall Med. 2011 Epub ahead of print.
    1. Iglesias-Garcia J, Lariño-Noia J, Dominguez-Muñoz JE. Elastography in the evaluation of chronic pancreatitis. Gastroenterol Hepatol. 2011;34:629–34.
    1. Janssen J, Dietrich CF, Will U, et al. Endosonographic elastography in the diagnosis of mediastinal lymph nodes. Endoscopy. 2007;39:952–7.
    1. Lariño-Noia J, Iglesias-García J, Álvarez-Castro A, et al. Usefulness of endoscopic ultrasound (EUS) elastography for the detection of malignant infiltration of mediastinal and abdominal lymph nodes. Gastroenterology. 2009;5:A–44.
    1. Săftoiu A, Vilmann P, Hassan H, et al. Analysis of endoscopic ultrasound elastography used for characterisation and differentiation of benign and malignant lymph nodes. Ultraschall Med. 2006;27:535–42.
    1. Xu W, Shi J, Zeng X, et al. EUS elastography for the differentiation of benign and malignant lymph nodes: a meta-analysis. Gastrointest Endosc. 2011;74:1001–9.
    1. Săftoiu A, Vilmann P, Ciurea T, et al. Dynamic analysis of EUS used for the differentiation of benign and malignant lymph nodes. Gastrointest Endosc. 2007;66:291–300.
    1. Kamoi K, Okihara K, Ochiai A, et al. The utility of transrectal real-time elastography in the diagnosis of prostate cancer. Ultrasound Med Biol. 2008;34:1025–32.
    1. Kapoor A, Mahajan G, Sidhu BS. Real-time elastography in the detection of prostate cancer in patients with raised psa level. Ultrasound Med Biol. 2011;37:1374–81.
    1. Giurgiu CR, Manea C, Crisan N, et al. Real-time sonoelastography in the diagnosis of prostate cancer. Med Ultrason. 2011;13:5–9.
    1. Miyagawa T, Tsutsumi M, Matsumura T, et al. Real-time elastography for the diagnosis of prostate cancer: evaluation of elastographic moving images. Jpn J Clin Oncol. 2009;39:394–8.
    1. Waage JE, Havre RF, Odegaard S, et al. Endorectal elastography in the evaluation of rectal tumours. Colorectal Dis. 2011;13:1130–7.
    1. Rustemovic N, Cukovic-Cavka S, Brinar M, et al. A pilot study of transrectal endoscopic ultrasound elastography in inflammatory bowel disease. BMC Gastroenterol. 2011;11:113.
    1. Allgayer H, Ignee A, Dietrich CF. Endosonographic elastography of the anal sphincter in patients with fecal incontinence. Scand J Gastroenterol. 2010;45:30–8.
    1. Iglesias-García J, Lariño-Noia J, Souto R, et al. Endoscopic ultrasound (EUS) elastography of the liver. Rev Esp Enferm Dig. 2009;101:717–9.
    1. Rustemovic N, Hrstic I, Opacic M, et al. EUS elastography in the diagnosis of focal liver lesions. Gastrointest endosc. 2007;66:823–4.

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